From the Chair: Why Professional Counselors Cannot Simply "Unionize"

One of the most common questions I hear from counselors is, “Why don’t we just unionize like nurses?” It is a fair question, but the legal and structural realities are very different. Let’s break it down.

Most nurses work as employees within hospitals, health systems, schools, or large organizations. Because they are employees, they may have rights under federal labor law, such as the National Labor Relations Act, to organize unions and collectively bargain over wages, working conditions, and benefits.

Professional counselors are often in a very different position. Many counselors work as independent contractors, private practice owners, or small business providers who contract individually with insurance companies. Under current federal antitrust law, independent businesses generally cannot collectively negotiate reimbursement rates in the same way employees can. If independent counselors joined together to demand specific pay rates from insurers, that could be interpreted as unlawful price fixing rather than protected union activity. Let’s break down the difference between an employee and an independent provider:

Employees (W-2), such as many hospital nurses, may have rights under labor law to unionize and collectively bargain with their employer.

Independent providers/businesses (W-9 or business entities) are generally treated as separate businesses under antitrust law, meaning collective negotiation over reimbursement can raise price-fixing concerns unless done through legally approved structures.

This is not unique to counselors if one considers why many medical doctors and primary care physicians (PCPs) are often not unionized. While employed doctors within hospital systems may unionize in some circumstances, physicians in private practice face many of the same barriers as independent medical doctors generally cannot collectively bargain over insurance reimbursement unless they are part of legally structured entities such as large medical groups, accountable care organizations, or clinically integrated networks.

Insurance contracts further complicate this issue. Most counselors sign individual provider agreements with commercial insurers, Medicaid managed care organizations, or third-party administrators. These contracts are typically offered on a take it or leave it basis. Once signed, the provider is usually bound by the insurer’s reimbursement structure, utilization review policies, credentialing rules, and audit provisions. Because each provider signs separately, counselors often negotiate from fragmented positions while large health systems negotiate with significantly more leverage. This creates one of the core challenges in our profession. Counselors

are essential to the behavioral health workforce, yet our legal structure often treats us as isolated vendors rather than a coordinated professional force.

In short, counselors cannot simply replicate the nursing union model because our workforce structure, employment status, and insurance relationships are fundamentally different. The future of counselor advocacy will likely depend less on traditional unionization and more on building legally sound systems of collective strength.

To change the system, we first have to understand the rules that shape it.